For breast cancer patients who have a mastectomy there used to be few options after removal. There were prosthesis, implants that would eventually be replaced, and details that just didn’t look natural.

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For the growing number of women who choose mastectomies, there’s also the question about what to do for the nipple. No nipple is an option, but so is a nipple and an additional tattoo to add color and dimension.

Diane – who still hasn’t told people in her office about her breast cancer or surgeries – has gotten very used to talking about her nipples.

“Let’s get over it, we have breasts. And you know what, we have nipples too,” she says. “The icing on the cake is the nipple tattoo.”

UT Southwestern Medical Center Plastic surgeon Dr. Nicholas Haddock talks with his patient, Diane, about the final stage in her breast reconstruction, the nipple tattoos.

Credit Lauren Silverman / KERA News

The Decision

In 2013, Diane found out she had breast cancer, and at 56 decided to have both breast removed – a double mastectomy.

For a while, she wore prosthesis. But she didn’t feel normal. Still, she says plastic surgery was a bit scary.

“I used to have such a bad opinion of plastic surgery,” Diane says, “Because to me it was the big lips, and the boobs and the Botox (…) but you know what? I remember the day I came in, Dr. Haddock took the bandages off, ran over to the mirror and I said, I’m starting to feel normal again.”

Not all women who have a mastectomy opt for breast reconstruction, although rates have gone up in the past decade. The women who do choose reconstruction have options that weren’t available to their mothers or grandmothers.

“It’s a lot like a tummy tuck,” Haddock explains. “If you had a tummy tuck that’s the tissue we usually remove, but in the tummy tuck we throw it away. In this situation instead I find those tiny blood vessels, bring it up to the chest and I plug those blood vessels into the chest.”

It’s a delicate surgery, reconnecting blood vessels that measure 2.5 millimeters, about the tip of a crayon. When Haddock finishes, a patient has both a breast, and skin in the form of a circle that acts as the areola.

The next step is making that lump of skin look like a nipple.

The inks and circle stencil template used to create realistic looking nipples.

Credit Lauren Silverman / KERA News

The Tattoo

While some women go to tattoo artists not associated with a medical facility, Diane chose to have her nipples tattooed at the UT Southwestern clinic where her plastic surgery was done.

Stacey Burden, one of the aestheticians trained to give women who’ve lost their breasts to cancer new nipples, says this tattoo is more superficial than a traditional tattoo.

The tubes of ink look like lip gloss or concealer. The pinks and browns have names like “Princess,” “Chocolate truffle,” and “Sinnamon.”

Burden starts with a larger 11-pronged needle to give general color, and twenty minutes later moves on to detail work, shading and adding tiny bumps called Montgomery glands.

“The first time I did a tattoo by myself,” Burden says, “the patient stood up and admired herself in the mirror and she looked perfect. And she cried and I cried.”

A Personal Decision

To some, the nipple tattoo may sound excessive, but Dr. Haddock says it’s part of the recovery process.

If mastectomy is covered by insurance, which it is for Diane, breast reconstruction – including the tattoo – is included. Just as insurers are recognizing the procedure, Haddock says tattoo artists and aesthetician are stepping up their game.

“In the past it might just be one solid color,” Haddock says, “and then it just looks like a cookie on someone’s breast. Whereas now, at least our tattoo artist is doing definition, creating shadow for the nipple, creating Montgomery glands, and some of the normal aspects of a normal nipple.”

Diane says it’s a very personal choice.

“My point is, reconstruction is out there and if women are not told this by their breast surgeon, it’s like they’re choosing from a menu that’s been partially redacted,” she says. “My view is you get all the facts together and then you make a decision.”

For Diane, the nipple tattoo is the last step in her physical recovery. A final detail that completes the picture.

In today's Morning Edition local block from the KERA Newsroom: Addison is home to the largest breast imaging company in the U.S. Even they have trouble convincing women to go in for regular mammograms. Lauren Silverman reports how Solis Women’s Health is trying to make the experience more comfortable. And the pricetag on a high-concept graphic novel by one North Texas artist: $15,000. Dallas Art Fair co-founder Chris Byrne reveals the secrets of his magician protagonist in an interview with Jerome Weeks.

Before Angelina Jolie told the world about her decision to have a double mastectomy, you might not have heard of BRCA1 or BRCA2. These are two genes where mutations are known to increase a woman’s risk of breast cancer. Jolie’s health risk was raised because of a mutation of the BRCA1 gene.

Scientists say we need to look beyond BRCA – to other genes that also increase a woman’s risk of breast cancer. KERA’s Lauren Silverman talks with Linda Robinson, assistant director of the Cancer Genetics Program at UT Southwestern about the future of genetic testing for breast cancer.